This newly-published page shows the results of a set of Gallup surveys in a number of African countries.
They found that attitudes varied by country. The percentage who agreed with "male circumcision reduces the risk of being infected with HIV/AIDS" varied from 26% to 80%. The percentage of respondents agreeing with the statement "all men should be circumcised" varied from 39% to 85%.
Interestingly, both sets of responses were strongly related to education level: the more educated people were, their responses to the first question were more consistent with the scientific evidence, and their responses to the second were more "pro-circumcision".
The question is, is it that more educated people are more aware of circumcision, and more receptive to scientific information about it? Or is it that less educated people are less resistant to anti-circumcision propaganda, perhaps lacking the critical thinking skills that allow us to see it for what it is?
Some follow-up questions: how do we ensure that information about circumcision reaches the less educated members of society? Or, how can the less educated members of society be protected from anti-circumcision propaganda?
Wednesday, 20 October 2010
Sunday, 23 May 2010
Reduced risk of sexual injuries in circumcised males
Yet another piggyback study using data from the HIV RCTs has been published. In this newly published study, using data gathered as part of the Kenyan trial, Mehta et al. report reduced risk of "penile coital injuries".
The authors report:
So, these injuries — while minor — are fairly common and disproportionately affect uncircumcised males.
The authors suggest that this may affect the risk of HIV acquisition. This seems perfectly plausible, though it would be a mistake, I believe, to say that it is "the" mechanism by which circumcision protects against HIV. What's becoming clear, I think, is that circumcision protects against HIV through multiple mechansisms acting simultaneously.
I wonder, though, whether these findings might partly explain the fact that several studies have found that dyspareunia (painful intercourse) is more common among uncircumcised males?
The authors report:
At baseline 1,775 (64.4%) men reported any coital injury including 1,313 (47.6%) soreness, 1,328 (48.2%) scratches, abrasions or cuts and 461 (16.7%) bleeding. On multivariable analysis coital injury risk was lower for circumcised than for uncircumcised men with soreness (OR 0.71, 95% CI 0.64-0.80), scratches/abrasions/cuts (OR 0.52, 95% CI 0.46-0.59), bleeding (OR 0.62, 95% CI 0.51-0.75) and any coital injury (OR 0.61, 95% CI 0.54-0.68).
So, these injuries — while minor — are fairly common and disproportionately affect uncircumcised males.
The authors suggest that this may affect the risk of HIV acquisition. This seems perfectly plausible, though it would be a mistake, I believe, to say that it is "the" mechanism by which circumcision protects against HIV. What's becoming clear, I think, is that circumcision protects against HIV through multiple mechansisms acting simultaneously.
I wonder, though, whether these findings might partly explain the fact that several studies have found that dyspareunia (painful intercourse) is more common among uncircumcised males?
Saturday, 8 May 2010
Fatally flawed: Bollinger's circumcision death calculations
Dan Bollinger (of the International Coalition for Genital Integrity) has published "LOST BOYS: AN ESTIMATE OF U.S. CIRCUMCISION-RELATED INFANT DEATHS". In it, he claims that circumcision causes 117 deaths per year in the United States. It's a lengthy paper, and is frankly rather tedious to wade through, but I thought it might be interesting to see how he derived his estimate:
(Here Bollinger references a figure he has provided previously: "Hospital discharge records reveal that, during the 1991–2000 decade, on average 35.9 boys died from all causes each year during their stay (average 2.4 days) in the hospital in which both their birth and circumcision occurred (Thompson Reuters, 2004).")
This is indeed a relatively safe assumption, though it is not one that actually gets us any closer to an answer.
This is extraordinary! Bollinger is, in effect, assuming that the difference between male and female death rates is due entirely to circumcision. But it is a well-established fact that male babies are more susceptible to deaths than females, and there is no evidence that this is due to circumcision. Indeed, if circumcision alone were responsible for the difference, then we might expect countries with low circumcision rates to have the same infant mortality rates among males and females. But in fact, that's not the case, as the following table shows:
Table: Infant mortality (IM) rates for selected countries. Derived from female rate table and male rate table.
Clearly, infant mortality rates are consistently higher among males regardless of circumcision rates. So Bollinger's approach is clearly flawed. When he is trying to estimate the risk due to circumcision he is actually estimating the risk due to being male!
But it gets even worse (this would be laughable if the subject weren't so serious). Even if we assume that Bollinger's method is sane and appropriate (in spite of evidence to the contrary), he manages to miscalculate those attributable to being male. If the rate is 40.4% higher among males then the observed rate (35.9) will be the rate in females plus 0.404 times that rate again (or 1.404 times the rate in females). So, to find the rate in females:
1.404f = 35.9
f = 35.9 / 1.404 = 25.57
And so the rate attributable to being male will be 40.4% of that, which is 10.33.
But, as noted, this is the rate attributable to being male, not to circumcision.
Bollinger expresses this with less than optimal clarity, but what he seems to be saying is that the ratio between deaths in the hospital stay (which Bollinger identifies as typically 2.4 days) and those after the hospital stay (but presumably within the first 28 days of life) is 7.72.
Frankly, that shouldn't be surprising. There are 10.7 times as many days in the latter period than there are in the former, so one would ordinarily expect more deaths simply due to there being more time in which people can die.
This multiplication is irrational. It stands to reason that there would be more deaths in the first 28 days than the first 2.4 days, simply because there is more time in which infants can die. If we look at the first 100 years of life, then the ratio will be even greater (in fact, the mortality rate over that period will be almost 100%), but would it make any sense to apply that ratio? Of course not — people die of other things than circumcision, and it wouldn't make any sense.
It doesn't make sense to apply this multiplication, either. Yes, a certain number of circumcision-related deaths will likely occur some time after the event, but it doesn't make any sense to assume, in effect, that any deaths in the period must be due to circumcision.
It is perhaps a little disingenuous to refer to these as "estimates". These are observations showing 1 death in 566,000 circumcisions (Speert), no deaths in 100,000 boys (Wiswell). Similarly, King reported no deaths in 500,000 circumcisions. So if we use 1 in 500,000 as a reasonable estimate, we would expect 2.6 deaths in 1.3 million circumcisions. Bollinger's errors have led him to a figure some 45 times greater than that which can be extrapolated from actual statistics!
Yes, I suppose the nice thing about imaginary numbers is that there is an inexhaustible supply of them.
Though the data previously cited are insufficient to establish a definitive death rate on their own, there is enough available information to calculate an estimate. Not all of the reported 35.9 deaths out of 1,243,392 circumcisions can be attributed to related causes.
(Here Bollinger references a figure he has provided previously: "Hospital discharge records reveal that, during the 1991–2000 decade, on average 35.9 boys died from all causes each year during their stay (average 2.4 days) in the hospital in which both their birth and circumcision occurred (Thompson Reuters, 2004).")
What portion, then, is circumcision-related and how may we extrapolate to the number of deaths after hospital release? What we can safely assume is that it is unlikely that any of these infants would have been subjected to the unnecessary trauma of circumcision if they had been in critical condition, or that they would have been circumcised after their death.
This is indeed a relatively safe assumption, though it is not one that actually gets us any closer to an answer.
Gender-ratio data can help extrapolate a figure. Males have a 40.4% higher death rate than females from causes that are associated with male circumcision complications, such as infection and hemorrhage,4 during the period of one hour after birth to hospital release (day 2.4), the time frame in which circumcisions are typically performed (CDC, 2004). Assuming that the 59.6% portion is unrelated to gender, we can estimate that 40.4% of the 35.9 deaths were circumcision-related. This calculates to 14.5 deaths prior to hospital release.
This is extraordinary! Bollinger is, in effect, assuming that the difference between male and female death rates is due entirely to circumcision. But it is a well-established fact that male babies are more susceptible to deaths than females, and there is no evidence that this is due to circumcision. Indeed, if circumcision alone were responsible for the difference, then we might expect countries with low circumcision rates to have the same infant mortality rates among males and females. But in fact, that's not the case, as the following table shows:
| Country | Est. neonatal circ. rate | IM (male) | IM (female) | IM m:f ratio |
|---|---|---|---|---|
| Israel | > 90% | 4.39 | 4.05 | 1.08 |
| Nigeria | 80-90% | 100.38 | 87.97 | 1.14 |
| United States | 50-80% | 6.90 | 5.51 | 1.25 |
| Australia | < 20% | 5.08 | 4.40 | 1.15 |
| United Kingdom | < 5% | 5.40 | 4.28 | 1.26 |
| France | < 5% | 3.66 | 2.99 | 1.22 |
| Finland | < 1% | 3.78 | 3.15 | 1.2 |
Table: Infant mortality (IM) rates for selected countries. Derived from female rate table and male rate table.
Clearly, infant mortality rates are consistently higher among males regardless of circumcision rates. So Bollinger's approach is clearly flawed. When he is trying to estimate the risk due to circumcision he is actually estimating the risk due to being male!
But it gets even worse (this would be laughable if the subject weren't so serious). Even if we assume that Bollinger's method is sane and appropriate (in spite of evidence to the contrary), he manages to miscalculate those attributable to being male. If the rate is 40.4% higher among males then the observed rate (35.9) will be the rate in females plus 0.404 times that rate again (or 1.404 times the rate in females). So, to find the rate in females:
1.404f = 35.9
f = 35.9 / 1.404 = 25.57
And so the rate attributable to being male will be 40.4% of that, which is 10.33.
But, as noted, this is the rate attributable to being male, not to circumcision.
But as is often the case with hemorrhage and infection, some circumcision-related deaths occur days, even weeks, after hospital release. The CDC’s online searchable database, Mortality: Underlying cause of death, 2004 (CDC), lists causes by various age ranges and reveals that the percentage of deaths after release, compared with deaths before, is 772% greater. This ratio is comparable to Patel’s (1966) 700% postrelease infection rate.
Bollinger expresses this with less than optimal clarity, but what he seems to be saying is that the ratio between deaths in the hospital stay (which Bollinger identifies as typically 2.4 days) and those after the hospital stay (but presumably within the first 28 days of life) is 7.72.
Frankly, that shouldn't be surprising. There are 10.7 times as many days in the latter period than there are in the former, so one would ordinarily expect more deaths simply due to there being more time in which people can die.
Multiplying the 772% adjustment factor for age-at-time-of-death by the 14.5 hospital-stay deaths calculated above, the result is approximately 112 circumcision-related deaths annually for the 1991–2000 decade, a 9.01/100,000 death-incidence ratio.
This multiplication is irrational. It stands to reason that there would be more deaths in the first 28 days than the first 2.4 days, simply because there is more time in which infants can die. If we look at the first 100 years of life, then the ratio will be even greater (in fact, the mortality rate over that period will be almost 100%), but would it make any sense to apply that ratio? Of course not — people die of other things than circumcision, and it wouldn't make any sense.
It doesn't make sense to apply this multiplication, either. Yes, a certain number of circumcision-related deaths will likely occur some time after the event, but it doesn't make any sense to assume, in effect, that any deaths in the period must be due to circumcision.
Applying this ratio to the 1,299,000 circumcisions performed in 2007, the most recent year for which data are available (HCUP, 2007), the number of deaths is about 117. This is equivalent to one death for every 11,105 cases, which is not in substantial conflict with Patel’s observation of zero deaths in 6,753 procedures. It is more than some
other estimates (Speert, 1953; Wiswell, 1989),
It is perhaps a little disingenuous to refer to these as "estimates". These are observations showing 1 death in 566,000 circumcisions (Speert), no deaths in 100,000 boys (Wiswell). Similarly, King reported no deaths in 500,000 circumcisions. So if we use 1 in 500,000 as a reasonable estimate, we would expect 2.6 deaths in 1.3 million circumcisions. Bollinger's errors have led him to a figure some 45 times greater than that which can be extrapolated from actual statistics!
but less than the overstated 230 figure derived from Gairdner (1949). Breaking this statistic down further, about 40% of these deaths (47) would have been from hemorrhage, and the remainder (70) from sepsis, using a hemorrhage-to-sepsis ratio for infant mortality (NCHS, 2004).
Yes, I suppose the nice thing about imaginary numbers is that there is an inexhaustible supply of them.
Tuesday, 20 April 2010
20 reasons revisited
SagaciousMama has posted an article entitled 20 Reasons I Did Not Circumcise My Son.
Now I'm supportive of parents who choose not to circumcise, as well as those who do, but this article is alarmingly misinformed. Here's my analysis.
Always? Even when local anaesthetic is used? If that were so, men circumcised as adults would report unbearable pain. But in fact, men circumcised under local anaesthetic generally report only mild pain, if any. (Eg., Long et al. report "No patient experienced pain during circumcision.")
This is a common anti-circ myth. In fact, the fingernail is fused to the nail bed; in contrast the foreskin's attachment to the glans is primed to detach anyway, and can easily be separated. (This is quite obvious from the many circumcision technique videos on the Internet, which show that the foreskin can be detached through moving a probe around, without excessive force.)
Here SagaciousMama cites only a number of weak sources. These sources speculate that neonatal circumcision causes numerous psychological problems, but they fall short of the most important quality of scientific work: testing one's hypothesis. In no cases do they provide any evidence showing that their theory is correct.
Until they do their theories don't really seem worthy of a response.
No, it isn't. "Mutilation" is defined as:
1. To deprive of a limb or an essential part; cripple.
The foreskin isn't a limb, and it is clearly not essential, since if it were we would not be able to survive without it.
2. To disfigure by damaging irreparably: mutilate a statue.
Circumcision neither damages nor disfigures. If it damaged the penis, then there would be clear evidence that the penis functioned better with a foreskin than without, but — if anything — the opposite seems to be true. "Disfigurement" is a little more subjective, but the fact that circumcision is widely perceived as a cosmetic improvement is incompatible with the notion that it is a disfigurement.
3. To make imperfect by excising or altering parts.
Again, this is somewhat subjective. That circumcision excises the foreskin is clear, but does this make the penis imperfect? Or does it make it more perfect?
Since SagaciousMama appears to indicate that her statement is a kind of timeless truth, frankly I think she needs something stronger than highly subjective assessments.
This is a repeat. See no. 1.
It would be impossible to alter a girl in this way: girls don't have penes. But, as a hypothetical, suppose that there was a form of minor surgery that could be performed on girls, that had multiple benefits, minimal risks, and no long-term harms. Would it be rational to oppose it?
Here SagaciousMama quotes the ever nutty circumstitions.com:
Oh dear. It's troubling that anyone can find this line of argument convincing. The basic idea is this: construct a list of positive claims that have ever been made about a subject, regardless of merit or basis in evidence. Now present them side by side. For example, you can show that hand-washing used to be a religious ritual in ancient times, and more recently, as germs became known, it was promoted for that reason. It's true, but what does it prove? That we should abandon handwashing? Of course not — such a conclusion is ludicrous.
With a little interpretation, what SagaciousMama is claiming here is that there are no advantages to circumcision. That's wildly incorrect: there are multiple health benefits to circumcision, including prevention of phimosis, balanoposthitis, urinary tract infection, HIV, HPV and (some) other STDs, penile cancer, etc. Some of these benefits are very minor, some less so, but to say that they don't exist is simply absurd.
Actually, you do, but you don't have to exercise that right if you don't want to.
What planet is SagaciousMama living on? There's a reasonable overview of study results at Wikipedia. Far from regret being "almost inevitable", high rates of satisfaction are commonplace.
According to what evidence? Almost none. Studies of penile sensitivity have almost invariably shown no statistically significant differences. See, eg., Masters & Johnson, Bleustein 2003, Bleustein 2005, Payne 2007. None of these studies were performed on recently circumcised men, and none were able to find evidence of this desensitisation.
True, and what do they (we, strictly speaking) describe? "After the procedure 82% of patients referred an upgrade on the quality of their sexual intercourse, ...", "Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," ...", "Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change."
There's really no reliable evidence that this is the case. SagaciousMama cites a dubious website on the subject, which is full of speculative nonsense but very little evidence.
True, though it's not exactly an argument against circumcision.
This is technically true, but neither is adult circumcision the same as infant circumcision (it almost invariably causes heavier scarring, for example), so whatever choice you make will have lasting consequences.
Yes, there are risks, albeit small. These should be considered alongside the risks associated with non-circumcision (such as death due to complications of UTI, for example).
This is too silly to deserve a response.
No. It doesn't.
I'm going to skip this one because, as far as I can tell, SagaciousMama is basically just saying that it is incompatible with her personal parenting philosophy. That seems a good reason not to circumcise.
Not really, no.
Yikes. This is frighteningly irrational: deciding against something because of the reasons why people used to do it. It's like being opposed to dancing because some tribes, somewhere in the world, perform rain dances in the belief that it will induce precipitation. So what? Given the number of human societies and their longevity, it seems inevitable that sometimes people do good things for stupid reasons.
This isn't a very rational argument. A considerable fraction of the world's population lack clean water, but this doesn't strike me as a compelling argument for having my water supply disconnected. The correct figure is probably closer to 60%, by the way.
This is simply nonsense.
Now I'm supportive of parents who choose not to circumcise, as well as those who do, but this article is alarmingly misinformed. Here's my analysis.
1) The Pain is Excruciating
Always? Even when local anaesthetic is used? If that were so, men circumcised as adults would report unbearable pain. But in fact, men circumcised under local anaesthetic generally report only mild pain, if any. (Eg., Long et al. report "No patient experienced pain during circumcision.")
The foreskin is attached like a fingernail (see #4).
This is a common anti-circ myth. In fact, the fingernail is fused to the nail bed; in contrast the foreskin's attachment to the glans is primed to detach anyway, and can easily be separated. (This is quite obvious from the many circumcision technique videos on the Internet, which show that the foreskin can be detached through moving a probe around, without excessive force.)
2) The procedure and pain has long lasting consequences.
Here SagaciousMama cites only a number of weak sources. These sources speculate that neonatal circumcision causes numerous psychological problems, but they fall short of the most important quality of scientific work: testing one's hypothesis. In no cases do they provide any evidence showing that their theory is correct.
Until they do their theories don't really seem worthy of a response.
3) It is genital mutilation.
No, it isn't. "Mutilation" is defined as:
1. To deprive of a limb or an essential part; cripple.
The foreskin isn't a limb, and it is clearly not essential, since if it were we would not be able to survive without it.
2. To disfigure by damaging irreparably: mutilate a statue.
Circumcision neither damages nor disfigures. If it damaged the penis, then there would be clear evidence that the penis functioned better with a foreskin than without, but — if anything — the opposite seems to be true. "Disfigurement" is a little more subjective, but the fact that circumcision is widely perceived as a cosmetic improvement is incompatible with the notion that it is a disfigurement.
3. To make imperfect by excising or altering parts.
Again, this is somewhat subjective. That circumcision excises the foreskin is clear, but does this make the penis imperfect? Or does it make it more perfect?
Since SagaciousMama appears to indicate that her statement is a kind of timeless truth, frankly I think she needs something stronger than highly subjective assessments.
4) In babies, the foreskin is attached like a fingernail.
This is a repeat. See no. 1.
5) I wouldn’t alter a girl in this way, and boys count, too.
It would be impossible to alter a girl in this way: girls don't have penes. But, as a hypothetical, suppose that there was a form of minor surgery that could be performed on girls, that had multiple benefits, minimal risks, and no long-term harms. Would it be rational to oppose it?
Here SagaciousMama quotes the ever nutty circumstitions.com:
For over a hundred years, circumcision has been a solution looking for a problem, and the problem has typically been the most frightening disease of the day - ... “masturbation insanity” in the 19th century, ... then tuberculosis, ... Sexually Transmitted Diseases (then called Venereal Disease or VD) after World War I, ... penile cancer in the 1930s, and ... * cervical cancer in the 1950s, when cancers were terrifyingly untreatable, ... urinary tract infections from 1982 onward, ... * and now HIV.
Oh dear. It's troubling that anyone can find this line of argument convincing. The basic idea is this: construct a list of positive claims that have ever been made about a subject, regardless of merit or basis in evidence. Now present them side by side. For example, you can show that hand-washing used to be a religious ritual in ancient times, and more recently, as germs became known, it was promoted for that reason. It's true, but what does it prove? That we should abandon handwashing? Of course not — such a conclusion is ludicrous.
6) It is pointless and absolutely unnecessary. ... There are no advantages to genital mutilation for either a boy or a girl however there are many disadvantages and risks.
With a little interpretation, what SagaciousMama is claiming here is that there are no advantages to circumcision. That's wildly incorrect: there are multiple health benefits to circumcision, including prevention of phimosis, balanoposthitis, urinary tract infection, HIV, HPV and (some) other STDs, penile cancer, etc. Some of these benefits are very minor, some less so, but to say that they don't exist is simply absurd.
7) I don’t have the right.
Actually, you do, but you don't have to exercise that right if you don't want to.
8.) Decreases sensitivity. ... This is the most studied and obvious aspect of this topic. Regardless of the volumes of studies on the tissue, the science, etc, the best evidence of this comes from studies of intact men who get circumcised as adults. Regret is almost inevitable. They do this for newly adopted religious reasons, misguided ideas or information on benefits and other reasons.
What planet is SagaciousMama living on? There's a reasonable overview of study results at Wikipedia. Far from regret being "almost inevitable", high rates of satisfaction are commonplace.
The foreskin is full of nerve endings and is the cause of natural lubrication. It is also a protective cover. Removing that cover exposes the glans of the penis to constant stimulation and rubbing against clothing. This idea makes an intact male shudder. Where some people think the exposed glans heightens sensitivity and sexual pleasure, the reverse is actually true. The penis desensitises to cope. The newly cut man will experience heightened sensitivity, however it is usually uncomfortable more than enjoyable and it does not last.
According to what evidence? Almost none. Studies of penile sensitivity have almost invariably shown no statistically significant differences. See, eg., Masters & Johnson, Bleustein 2003, Bleustein 2005, Payne 2007. None of these studies were performed on recently circumcised men, and none were able to find evidence of this desensitisation.
If you ask a circumcised man about sexuality and sensitivity he will usually tell you everything is fine, great, just dandy. However, he doesn’t know it any other way. You can’t miss something you’ve never had. Only those who have been circumcised as adults have that perspective.
True, and what do they (we, strictly speaking) describe? "After the procedure 82% of patients referred an upgrade on the quality of their sexual intercourse, ...", "Compared to before they were circumcised, 64.0% of circumcised men reported their penis was "much more sensitive," ...", "Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change."
9) Causes problems for female partners.
There's really no reliable evidence that this is the case. SagaciousMama cites a dubious website on the subject, which is full of speculative nonsense but very little evidence.
10) The option will always be there when he grows up.
True, though it's not exactly an argument against circumcision.
11) It is irreversible. ... Restoration is not the same.
This is technically true, but neither is adult circumcision the same as infant circumcision (it almost invariably causes heavier scarring, for example), so whatever choice you make will have lasting consequences.
12) Risk of Physical Damage and Death.
Yes, there are risks, albeit small. These should be considered alongside the risks associated with non-circumcision (such as death due to complications of UTI, for example).
13) Babies Tell You They Don’t Want To Be Circumcised.
This is too silly to deserve a response.
14) Interferes With Breastfeeding.
No. It doesn't.
15) It Goes Against Natural and Attachment Parenting
I'm going to skip this one because, as far as I can tell, SagaciousMama is basically just saying that it is incompatible with her personal parenting philosophy. That seems a good reason not to circumcise.
16) It is Medieval, Shocking Barbaric and Weird. ... and ... 17) Spread eagled restraint is like torture to a baby.
Not really, no.
18.) The historical reasons for it are morality based
Yikes. This is frighteningly irrational: deciding against something because of the reasons why people used to do it. It's like being opposed to dancing because some tribes, somewhere in the world, perform rain dances in the belief that it will induce precipitation. So what? Given the number of human societies and their longevity, it seems inevitable that sometimes people do good things for stupid reasons.
19) 80% of the World’s Males are Intact.
This isn't a very rational argument. A considerable fraction of the world's population lack clean water, but this doesn't strike me as a compelling argument for having my water supply disconnected. The correct figure is probably closer to 60%, by the way.
20) The Foreskin is a Necessary and Amazing Anatomical Structure.
This is simply nonsense.
Saturday, 6 March 2010
Circumcision and human rights
This is a fascinating article from UNAIDS, entitled "Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming: Guidance for decision-makers on human rights, ethical and legal considerations".
I think this quote captures its essence:
(Emph. added)
I'll also add the following quote re infant circumcision:
It's an excellent document, worth reading in full.
I think this quote captures its essence:
Given that it reduces a man’s risk of acquisition of HIV through penile–vaginal intercourse, male circumcision provides an opportunity to reinforce HIV prevention efforts and thereby promote human rights. A human rights-based approach to introducing or expanding male circumcision services requires measures to ensure that the procedure can be carried out safely, under conditions of informed consent, and without discrimination. From a public health and human rights perspective, it also requires that governments implement male-circumcision programmes in the context of a comprehensive HIV prevention framework. This will ensure that “risk compensation” (i.e. increases in risky behaviour sparked by decreases in perceived risk) (Cassell et al., 2006) does not undermine the partially protective effects of male circumcision for men.
(Emph. added)
I'll also add the following quote re infant circumcision:
Studies have shown that the circumcision of infants is simpler and carries fewer medical risks than circumcision of older people. Parents considering circumcision of an infant boy should be provided with all the facts so they can determine the best interest of the child. In these cases, determining the best interests of the child should include diverse factors—the positive and negative health, religious, cultural and social benefits. Because the HIV-related benefits of circumcision only arise in the context of sexual activity, and because male circumcision is an irreversible procedure, parents may consider that the child should be given the option to decide for himself when he has the capacity to do so.
It's an excellent document, worth reading in full.
Sunday, 28 February 2010
Oh dear: Christiane Northrup on circumcision
Christiane Northrup's article entitled "We Need To Stop Circumcision" has already received some criticism from other bloggers. I thought I'd add my own thoughts...
Let's address these arguments one by one:
The facts: about a third of men — perhaps 40% — are circumcised worldwide. Some physicians advocated circumcision to prevent masturbation in the late 1800s, and anti-circumcision activists are fond of quoting them, but there's no evidence that this was the main reason for the introduction of circumcision, and it certainly wasn't the only one. In fact, Gollaher, in his book "Circumcision: A History of the World's Most Controversial Surgery" (which is one of the more neutral books on the subject) dedicates a mere 12 of his 253 pages to the subject of masturbation.
As I have explained previously: It is not meaningful to compare female genital cutting to circumcision. Female genital cutting is a net harm, with no known medical benefits, immediate risks, and a considerable chance of permanent harm. Society passes laws to protect the vulnerable from harm, and so it makes sense to protect children from female genital cutting. But - applying the same principle - it doesn't make sense to legislate against circumcision, because there is no net harm. Most reasonable people, weighing the risks and benefits, come to the conclusion that it is neutral or beneficial.
Doubtless this argument is chosen for emotional appeal, but rationally, there's a strong case against circumcision without anaesthesia, but that's not an argument against circumcision.
It's difficult to know how to respond to this. How should one respond to someone who plainly states such falsehoods?
As a point of accuracy, Gray did not perform all three studies.
It's concerning to see this argument made by an educated person. Comparisons between selected countries are meaningless. Consider the following image. It's a simulation of HIV rates in 200 hypothetical countries (a very primitive simulation, for purposes of illustration only). The vertical axis represents HIV rates (you can ignore the horizontal axis). The black points represent countries with high circumcision rates — the average HIV rate is 1. The red points represent countries with low circumcision rates — the average HIV rate is 2. So, on average, countries with low circumcision rates have higher HIV rates. But because of the fact that the ranges overlap, it's easy to find black points that are higher than several red points. Let me make that point more clearly: we should expect to be able to find countries with high circumcision rates that have higher HIV rates than some selected countries with low circumcision rates. This is the case with real HIV rates, too (as well as rates of other diseases), and it happens because, in addition to random variation, there are other factors that affect the rates, such as levels of education, condom usage, sex practices, etc.
Country-level comparisons are extremely weak, even when you use a large sample of countries. They're nothing but a joke when small numbers of selected countries are compared. There's really no substitute for rigorous epidemiological studies.
It seems to me that Northrup is setting up a straw man here. Nobody is arguing that it is "nearly impossible" to keep an uncircumcised penis clean. But it is difficult to deny that it does require a little more work, and also that a circumcised penis is, on average, cleaner.
Reading between the lines a little, I think Northrup is saying that she has been unable to persuade parents of her viewpoint. Maybe that's because it isn't very persuasive?
(I'm skipping two paragraphs here.)
Actually, studies have documented no such thing. What they actually indicate, on balance, is that there is basically no difference. It is disturbing that Northrup misrepresents the evidence.
In the weeks ahead, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) are likely to publish a recommendation that all infant boys undergo circumcision. In the weeks ahead, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) are likely to publish a recommendation that all infant boys undergo circumcision. This is a huge mistake. Circumcision is an unnecessary procedure that is painful and can lead to complications, including death. No organization in the world currently recommends this. Why should we routinely remove normal, functioning tissue from the genitals of little boys within days of their birth?
Let's address these arguments one by one:
- It's unnecessary, painful, and can lead to complications. Yes, it's unnecessary, but parents do many things for their children that aren't strictly necessary, from vaccinations to good diet to education. They may not be required, but that doesn't mean that they aren't beneficial. Painful? Yes, if anaesthesia isn't used. Complications? Yes, there's a risk, but that has to be weighed against the risks associated with lack of circumcision.
- No organisation currently recommends it. That's not a rational argument for saying that no organisation should recommend it not. Intact America made the same mistake; I analysed their argument here.
- Why should it be done? This isn't strictly speaking an argument, so I'll leave it for now.
The vast majority of the world's men, including most Europeans and Scandinavians, are uncircumcised. And before 1900, circumcision was virtually nonexistent in the United States as well--except for Jewish and Muslim people, who've been performing circumcisions for thousands of years for religious reasons. Believe it or not, circumcision was introduced in English-speaking countries in the late 1800s to control or prevent masturbation, similar to the way that female circumcision--the removal of the clitoris and labia--was promoted and continues to be advocated in some Muslim and African countries to control women's sexuality. [1]
The facts: about a third of men — perhaps 40% — are circumcised worldwide. Some physicians advocated circumcision to prevent masturbation in the late 1800s, and anti-circumcision activists are fond of quoting them, but there's no evidence that this was the main reason for the introduction of circumcision, and it certainly wasn't the only one. In fact, Gollaher, in his book "Circumcision: A History of the World's Most Controversial Surgery" (which is one of the more neutral books on the subject) dedicates a mere 12 of his 253 pages to the subject of masturbation.
Routine female circumcision, which has been practiced in some cultures, is completely unacceptable. Few people would argue otherwise. In fact, the United Nations has issued a decree against it. Circumcision is a form of sexual abuse whether it's done to girls or boys. We justify male infant circumcision by pretending that the babies don't feel it because they're too young and it will have no consequences when they are older. This is not true. Women who experience memories of abuse in childhood know how deeply and painfully early experiences leave their marks in the body. Why wouldn't the same thing apply to boys?
As I have explained previously: It is not meaningful to compare female genital cutting to circumcision. Female genital cutting is a net harm, with no known medical benefits, immediate risks, and a considerable chance of permanent harm. Society passes laws to protect the vulnerable from harm, and so it makes sense to protect children from female genital cutting. But - applying the same principle - it doesn't make sense to legislate against circumcision, because there is no net harm. Most reasonable people, weighing the risks and benefits, come to the conclusion that it is neutral or beneficial.
In medical school, I was taught that babies couldn't feel when they were born and therefore wouldn't feel their circumcision. Why was it, then, that when I strapped their little arms and legs down on the board (called a "circumstraint"), they were often perfectly calm; then when I started cutting their foreskin, they screamed loudly, with cries that broke my heart? For years, in some hospitals, surgery on infants has been carried out without anesthesia because of this misconception!
Doubtless this argument is chosen for emotional appeal, but rationally, there's a strong case against circumcision without anaesthesia, but that's not an argument against circumcision.
From the 1980s through today, as the tide has been turning against male circumcision, misleading medical information has begun to surface (yet again) in support of circumcision. This information supports the belief that men with foreskins are more likely to get viral or bacterial infections and pass them on; that the foreskin is tender and thin, and therefore more prone to tiny cuts through which germs can be transmitted. New justifications, such as circumcision to prevent penile and cervical cancer, too often receive the blessing of the medical establishment. But these are justifications that science has been unable to support. Nor is there any scientific proof that circumcision prevents sexually transmitted diseases.
It's difficult to know how to respond to this. How should one respond to someone who plainly states such falsehoods?
This includes the recent studies done in Kenya, South Africa, and Uganda by Ronald H. Gray, a professor at Johns Hopkins University. He recently reported that men who were circumcised were less likely by half to contract HIV virus and less likely by one-third to become infected with HPV and herpes. [2]
As a point of accuracy, Gray did not perform all three studies.
While this sounds promising, I agree with my colleague George Denniston, M.D., who said, "The United States has high rates of HIV and the highest rate of circumcision in the West. The "experiment" of using circumcision to stem HIV infection has been running here for decades. It has failed miserably. Why do countries such as New Zealand, where they abandoned infant circumcision 50 years ago, or European countries, where circumcision is rare, have such low rates of HIV?" [3]
It's concerning to see this argument made by an educated person. Comparisons between selected countries are meaningless. Consider the following image. It's a simulation of HIV rates in 200 hypothetical countries (a very primitive simulation, for purposes of illustration only). The vertical axis represents HIV rates (you can ignore the horizontal axis). The black points represent countries with high circumcision rates — the average HIV rate is 1. The red points represent countries with low circumcision rates — the average HIV rate is 2. So, on average, countries with low circumcision rates have higher HIV rates. But because of the fact that the ranges overlap, it's easy to find black points that are higher than several red points. Let me make that point more clearly: we should expect to be able to find countries with high circumcision rates that have higher HIV rates than some selected countries with low circumcision rates. This is the case with real HIV rates, too (as well as rates of other diseases), and it happens because, in addition to random variation, there are other factors that affect the rates, such as levels of education, condom usage, sex practices, etc.
Country-level comparisons are extremely weak, even when you use a large sample of countries. They're nothing but a joke when small numbers of selected countries are compared. There's really no substitute for rigorous epidemiological studies.
Similarly, one of the main reasons people choose to have their child circumcised is they believe that it's nearly impossible to keep an uncircumcised penis clean. This also isn't true. And people make the mistake of thinking that they have to retract the foreskin to keep it clean. They don't. In fact, retracting the foreskin before it's meant to be retracted creates adhesions and infections. It sometimes doesn't retract on its own until a boy is as old as seven. Often, there isn't an opening between the glans penis and the foreskin. So you gently retract it every year on the child's birthday until it's fully retractable. Only then does it need to be cleaned, and you can teach a boy exactly how to do this.
It seems to me that Northrup is setting up a straw man here. Nobody is arguing that it is "nearly impossible" to keep an uncircumcised penis clean. But it is difficult to deny that it does require a little more work, and also that a circumcised penis is, on average, cleaner.
Emotions run very high around the subject of circumcision, a perfect example of the strength and influence of first chakra cultural programming on our beliefs and emotions. This programming is so ingrained that many people cannot even discuss the subject of circumcision without guilt, denial, or other strong emotions. I know from years of experience that even addressing the subject of the baby boy's bodily integrity, choices, and pain isn't enough to change a belief that's been ingrained in the child's parents from their own birth.
Reading between the lines a little, I think Northrup is saying that she has been unable to persuade parents of her viewpoint. Maybe that's because it isn't very persuasive?
(I'm skipping two paragraphs here.)
Circumcision also has profound implications for male sexuality. Studies document that the amount of pleasure a man can receive during intercourse is greater in uncircumcised males. That's because the male foreskin, like the clitoris, is richly innervated for maximum sexual pleasure. Sexual researchers have determined that men with the original configuration (with the foreskin) are more likely to feel the most pleasure when they make love in a certain way. Without getting into details here, as it turns out, this "natural" sex is more likely to enhance a woman's pleasure, too. I've written about this extensively in Women's Bodies, Women's Wisdom.
Actually, studies have documented no such thing. What they actually indicate, on balance, is that there is basically no difference. It is disturbing that Northrup misrepresents the evidence.
Tuesday, 16 February 2010
CDC consultation report
Male Circumcision in the United States for the Prevention of HIV Infection and Other Adverse Health Outcomes: Report from a CDC Consultation has now been published.
It is a lengthy document, worth reading in full. I'll just highlight here what I think are the most interesting recommendations:
It is a lengthy document, worth reading in full. I'll just highlight here what I think are the most interesting recommendations:
- With respect to HIV prevention, MC should be framed as one of several partially effective risk-reduction alternatives for heterosexual men that should be used in combination for maximal protection.
- Recommendations for infant and adolescent/adult MC should be framed as interventions to promote genital health and hygiene, including HIV, STI, and UTI prevention and other outcomes.
- Recommend reimbursement for MC by public and private insurers to ensure equal access across states, to all socioeconomic groups, and in special settings (e.g., military or prisons).
- In collaboration with other HHS agencies and health insurers, assess public and private insurance coverage for elective neonatal MC.
- Medical benefits outweigh risks for infant MC, and there are many practical advantages of doing it in the newborn period.
- Benefits and risks should be explained to parents to facilitate shared decision-making in the newborn period.
CDC, AAP, and others should make/update recommendations about infant circumcisions for HIV and broader health concerns. - Develop educational resources about infant circumcision for parents, practitioners, and the public.
Wednesday, 10 February 2010
Deliberate distortion from anti-circumcision activist
I spent some time trying to decide whether I should post this. It was a difficult decision for me. On one hand, what follows is part of a message to a private mailing list, and those posting to such lists do so with the expectation of privacy. On the other hand, it illustrates intent to mislead on the part of a prominent anti-circumcision activist, and people have a right to know about this sort of thing.
In the end, I decided to post it.
Hugh Young is a well-known anti-circumcision activist (or "intactivist", as they often call themselves) from New Zealand. He is the owner of the "circumstitions.com" website.
INTACT-L is a mailing list run by the anti-circumcision website "cirp.org", for discussion of anti-circumcision issues in general.
Recently, participants on INTACT-L have been discussing the anticipated policy statement from the American Academy of Pediatrics. One participant suggests that the anti-circumcision activists write a statement for the AAP:
To which Hugh Young replies:
(Emphasis added.)
Now, if anti-circumcision activists want to write a "policy statement" for the AAP, that's up to them. It seems a waste of time to me, but it's their time to waste, after all. What I find really alarming here is that Young explicitly indicates that he wants to mislead people. He wants people to believe that the (hypothetical) version authored by the anti-circumcision lobby is the real policy statement.
I'm sorry to say that I believe that what's unusual here is the admission rather than the intent, but even so the admission is startling enough. It makes one think: if the anti-circumcision "message" is so strong, why would anyone feel the need to deceive people?
Does he not have any concept of ethics? Apparently not.
In the end, I decided to post it.
Hugh Young is a well-known anti-circumcision activist (or "intactivist", as they often call themselves) from New Zealand. He is the owner of the "circumstitions.com" website.
INTACT-L is a mailing list run by the anti-circumcision website "cirp.org", for discussion of anti-circumcision issues in general.
Recently, participants on INTACT-L have been discussing the anticipated policy statement from the American Academy of Pediatrics. One participant suggests that the anti-circumcision activists write a statement for the AAP:
Rather than waiting for them to do the wrong thing, as they surely will, let's tell them what the right thing is.
To which Hugh Young replies:
From: Hugh Young
To: intact-l@cirp.org
Subject: Re: The AAP's new position statement on circumcision
Date: Feb 10, 2010 7:23:56 AM
[...]
A good point. Brian Morris drafted his version of a statement for the RACP but it was so over the top they would have laughed at it (though they still haven't issued theirs). We need to make ours something they could/should agree to. If it gets published so that people mistake it for the real thing, so much the better. If we can ease them out of legal action for past circumcisions, they'd appreciate that too - that's their big fear if they go straight from "neutrality" to condemnation without giving all present victims time to die off.
(Emphasis added.)
Now, if anti-circumcision activists want to write a "policy statement" for the AAP, that's up to them. It seems a waste of time to me, but it's their time to waste, after all. What I find really alarming here is that Young explicitly indicates that he wants to mislead people. He wants people to believe that the (hypothetical) version authored by the anti-circumcision lobby is the real policy statement.
I'm sorry to say that I believe that what's unusual here is the admission rather than the intent, but even so the admission is startling enough. It makes one think: if the anti-circumcision "message" is so strong, why would anyone feel the need to deceive people?
Does he not have any concept of ethics? Apparently not.
Sunday, 24 January 2010
The Effects of Circumcision on the Penis Microbiome
Here is an interesting study. Using men from the intervention arm of the Ugandan RCT, the researchers studied the microbiological flora of the penis before and after circumcision.
The researchers found that there was a significant change in the types of bacteria found on the penis. In particular, the number of anaerobic bacteria fell significantly following circumcision.
The discovery that circumcision alters the penile flora is nothing new. Many studies have investigated this previously (for an overview see refs 12-22 in my letter here), and have come to similar conclusions.
The authors speculate that the presence of anaerobic bacteria on the uncircumcised penis might promote inflammatory conditions which activate immune cells that, in turn, act as a magnet for HIV.
It also, of course, helps to explain the fact that circumcised males enjoy reduced risk of urinary tract infections and local infections such as balanitis.
The researchers found that there was a significant change in the types of bacteria found on the penis. In particular, the number of anaerobic bacteria fell significantly following circumcision.
The discovery that circumcision alters the penile flora is nothing new. Many studies have investigated this previously (for an overview see refs 12-22 in my letter here), and have come to similar conclusions.
The authors speculate that the presence of anaerobic bacteria on the uncircumcised penis might promote inflammatory conditions which activate immune cells that, in turn, act as a magnet for HIV.
It also, of course, helps to explain the fact that circumcised males enjoy reduced risk of urinary tract infections and local infections such as balanitis.
Friday, 22 January 2010
Cost-effectiveness of newborn circumcision in reducing lifetime HIV risk among US males.
Here is a fascinating study by researchers from the CDC. Using data from randomised controlled trials, they modelled the effect of neonatal circumcision on lifetime risk of HIV in the United States.
The authors assumed (as far as I can tell) that circumcision had an effect only on heterosexual transmission. This is a conservative assumption, so we should bear in mind that the results will also be conservative estimates.
They found that neonatal circumcision "reduced the 1.87% lifetime risk of HIV among all males by about 16%" (that is, it reduced by about 0.3% to about 1.6%). This effect varied by race, from 7.9% for white men to 20.9% for black men. They also found "lower expected HIV-related treatment costs and a slight increase in [Quality-adjusted life years]".
The CDC's forthcoming recommendations re neonatal circumcision are in the news at the moment (see, for example, Debate on circumcision heightened as CDC evaluates surgery [Washington Post, 19 Jan]), and of course there is much speculation about what those recommendations will be. To my mind, there's an interesting clue in the conclusions of this paper:
(Emphasis added.)
The authors assumed (as far as I can tell) that circumcision had an effect only on heterosexual transmission. This is a conservative assumption, so we should bear in mind that the results will also be conservative estimates.
They found that neonatal circumcision "reduced the 1.87% lifetime risk of HIV among all males by about 16%" (that is, it reduced by about 0.3% to about 1.6%). This effect varied by race, from 7.9% for white men to 20.9% for black men. They also found "lower expected HIV-related treatment costs and a slight increase in [Quality-adjusted life years]".
The CDC's forthcoming recommendations re neonatal circumcision are in the news at the moment (see, for example, Debate on circumcision heightened as CDC evaluates surgery [Washington Post, 19 Jan]), and of course there is much speculation about what those recommendations will be. To my mind, there's an interesting clue in the conclusions of this paper:
Racial and ethnic groups who could benefit the most from circumcision may have least access to it due to insurance coverage and state Medicaid policies, and these financial barriers should be addressed. More data on the long-term protective effect of circumcision on heterosexual males as well as on its efficacy in preventing HIV among MSM would be useful.
(Emphasis added.)
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